When are adnexal cysts considered urgent and what is the appropriate management?

From the Guidelines

Adnexal cysts require urgent evaluation when they present with severe pain, signs of rupture, torsion, or hemorrhage, or when malignancy is suspected, as indicated by the most recent study 1. Urgent cases typically involve acute severe pelvic pain, fever, hypotension, peritoneal signs, or large complex cysts with concerning features on imaging. Management of urgent adnexal cysts generally requires prompt surgical intervention, often via laparoscopy or laparotomy depending on the patient's stability and cyst characteristics. Some key points to consider in the management of adnexal cysts include:

• For ovarian torsion, detorsion and cyst removal is preferred to preserve ovarian function, as supported by recent guidelines 1.
• Ruptured cysts with significant bleeding may require hemostatic measures and possibly oophorectomy in severe cases.
• While waiting for surgery, patients should receive appropriate pain management (typically IV NSAIDs or opioids), antiemetics as needed, and IV fluids if hemodynamically compromised.
• Laboratory tests including CBC, comprehensive metabolic panel, and tumor markers (CA-125, HCG, AFP) should be obtained, as recommended by recent studies 1.
• Urgent gynecological consultation is essential, and patients should remain NPO in anticipation of possible surgery. The urgency stems from the risk of permanent ovarian damage in torsion cases (which can occur within hours), potential severe blood loss from hemorrhagic cysts, and the need to rule out malignancy in complex cysts with concerning features, as highlighted by recent research 1. In terms of imaging, ultrasound is the mainstay of evaluation of adnexal masses, due to its accuracy, safety, and availability, as noted in recent studies 1. Laparoscopic surgery is preferred over open surgery when possible, due to consistently demonstrated shorter hospital length of stay and less postoperative pain, as supported by recent evidence 1.

From the Research

Urgent Adnexal Cysts

Adnexal cysts are considered urgent in certain situations, including:

• Adnexal torsion, which is a surgical emergency that requires prompt diagnosis and treatment to preserve the ovary 2, 3, 4
• Ectopic pregnancy, which must be ruled out in women of reproductive age 5, 6
• Ovarian cancer, which may present with symptoms such as abdominal or pelvic pain, increased abdominal size or bloating, difficulty eating, or rapid satiety 5, 6

Diagnostic Criteria

The diagnosis of adnexal torsion is often challenging, but certain imaging findings are highly suggestive, including:

• A 'whirlpool' sign, 'follicular ring' sign, enlarged/edematous ovary, and absent Doppler flow to the ovary on ultrasound 2
• Ovarian enlargement, adnexal mass, twisting of the vascular pedicle, edematous and heterogeneous appearance of the ovary, peripheral ovarian follicles, free fluid, uterine deviation towards the side of torsion, adnexal fat stranding, tubal dilatation, and decreased adnexal enhancement on CT or MRI 3, 4

Management

The management of adnexal cysts depends on the underlying cause, but may include:

• Surgical detorsion for adnexal torsion, with ovarian conservation even in cases where the tissue appears necrotic 2
• Referral to a gynecologist or gynecologic oncologist for suspected ovarian cancer or other complex cases 5, 6
• Expectant management for asymptomatic benign adnexal masses 6